HomeMy WebLinkAboutCLE201200050 Legacy Document 2012-03-06Application for Zonin:y Clearance
Is-
CLE # 26 1 2 �
OFFICE USE O L
3CD Date: " f "' �—
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # Staff:
PARCEL INFORM[4?P� r �,D ` ,� v 0 ( C /L C'�/
0 '� t Existing Zoning h �(J1� f� 011ui ellrun
Tax Map and Parcel: Ci''
AA t
Parcel Owner: D'� NA 1Z�f �-sL c-
-� tt //
Parcel Address4 qo PJMrnK 4&:kf City( .�'ii'��.LJ �� V/��` Zip2�
(include suite or floor)
PRIMARY CONTACT
av, b AOM247
Who should we call /write concerning this project?
i. V1 `�b(r 0; e V/T Zip
Address :
t, i�;9
Office Phone: 2 V•5 ell # �C'z' 7a'x T 3� E -mail `
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of naamee New business
/Change
Business Name /Type: (/1`�� #?/ P • /
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaFes, number of
vehicl , and any addition inf m do t yo can provide: 6f F
Ld
*1rillolt r only be a 'd n t e parce for which it is apirt5ved. Ifyyou change, intensify or move the use to a new location, a new Zoning
Clearance will be required.
I hereby certify that I own or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my knowledge. I have read the conditions of approval, and II understand them, and that I will abide by them.
Signature l/�-y` �v` �l V�� Printed &I Ir 1/4i'r'� P/
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[� ] Bacldlow prevention device and/or current test data needed for thus site. Contact ACSA, 977 -4511, x117.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date 4—
I-1/ `vim
I
Zoning Official _ Date ��/
Other Official Date
County of Albemarle Department of uommumry Leveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
G
Intake to complete the following:
YOseI,
Is HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y
Wil there be food preparation? .
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on private well or ublic water
If private well, provide Health epa ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that zgic Is parcel on septic se
Y ou be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y /�N
ViTil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonin to com lete the followin :
Reviewer to complete the follow /ing:
Square footage of Use: uOr
Permitted as: h� /A )f-�
Under Section:
Supplementary regulations section:
Parking formula:
/
spaces:,,g�
Y
Items to be verified in "the field:
Inspector:
Notes:
Date:
t2 r-
Violations:
Y/.0
If so, List:
Proffers:
Y/
If so, ist:
Variance:
Y/
If so, st:
SP's:
Y/V
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application, Z& 0,,� n16 Ciz -,py:- /A -P
County application name and number]
Gl . t2A)r *4 ,
was provided to -�.� -� V)F�iN..AQ : L- L the owner of record of Tax Map
[name(s- of the kcord own Es of the parcel]
and Parcel Number
7Hand entified below: delivering a copy of the application to I&A,
[Name of the record own r if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office for that entity]
by delivering a copy of the application in the
on ° ®
Date
Mailing a copy of the application to
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
office for that entity]
on
Date
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
V &Ayr�
Si . a re of Appl�ant
iit)VIXH D - 1D
Print Applicant Name
Date
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